Malnutrition. At initial diagnosis, many patients with HNC have significant weight loss.33 Unfortunately, the required complex treatment modalities increase malnutrition rates and decrease quality of life. 34 Preventive strategies are, therefore, key in improving patients’ overall health. The authors recommend that GPs consider early nutritional consultations and as-needed speech therapy evaluations to provide preventive strategies and exercises to maintain proper swallowing function. 35 Patients who are unable to eat because of aspiration caused by a large tumor should be admitted for preoperative gastric tube placement to improve nutrition and, ultimately, surgical outcome. A large percentage of veterans with HNC also have depression, which may lead to decreased appetite. 36 Mental health consultations can help in these circumstances, as can use of mirtazapine, which increases appetite and treats depression-related symptoms.
Pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be recommended for relief of uncontrolled mild to moderate pain, but they must be discontinued 1 week before surgery to reduce the risk for bleeding complications. The NSAIDs should be avoided entirely in patients with untreated friable tumors of the aerodigestive tract. In patients with biopsy-proven cancer, pain control can involve opiates per World Health Organization guidelines. 37 Patients with head and neck SCC often have neuropathic pain, which is more effectively treated with gabapentin.
Alcohol drinking and tobacco smoking . Promoting cessation of these habits is essential for all patients, including those already diagnosed with cancer. Encouraging cessation as well as overall healthy lifestyle choices can reduce cancer risk and improve overall health—and may be the single most efficacious intervention a physician can offer.
Referral
Most patients with suspected HNC should be referred to Oto-HNS. In cases in which lymphoma is most highly suspected, medical oncology is the most appropriate initial referral. Early dental consultation is also necessary if an obturator will be needed (eg, as with a hard palate malignancy) or if irradiation is planned (radiation-induced xerostomia significantly increases the risk for dental caries). 38 For all new cancer diagnoses, the GP can contact the Oto-HNS specialist for help in tailoring the patient evaluation to the practices and resources at the GP’s home institution and reduce time to treatment.
Conclusion
General practitioners are essential in identifying and triaging veterans with HNC. High-risk patients with a growing mass require proper assessment, including a thorough history and physical examination, FNA for diagnosis, and appropriate specialist referral. Although this article provides a helpful framework for thinking about patients with HNC, the authors encourage GPs to check the National Comprehensive Cancer Network guidelines for additional information on the topics covered here. With this knowledge, GPs can improve outcomes for veterans with HNC.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner , Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
